I have been on holiday for the last month, but now we are back on track and start the week with a low back pain case. Heading towards L5 radiculopathy, I have to admit that there is no current article on this topic – so I use the bible (Mumenthaler, Stöhr, Müller-Vahl), which is the best book I have on the topic. Then there are our german guidelines which are good but far from evidence-based.
For the differential of radiculopathy, here is a short mnemonic I got of the web:
– Herpes zoster
– Inflammatory (sarcoid, Syphilis, Lyme, TB, HIV, Cryptococcosis)
– Mass (tumours, cysts, hematomas etc.)
Here are some core messages:
- The lumbar disc tends to be higher than you think.
- They have to do something to get better – make them responsible, have them do things rather than stay calm (even if the things they do don’t help according to studies): No one studied doing nothing vs. something – they all compared to placebo or sham therapy (which is doing something).
- Hit them hard, fire on all cannons (in order to prevent chonification)
- Pain killers for muscular skeletal things
- Opiates for worse pain
- Muscle relaxants if any muscular reaction prevails and to prevent it during remobilisation
- Antidepressants and anticonvulsants for the neuropathic part of the pain
- Get out quick (reduce medication quickly, especially the opiates)